COVID-19 Reporting Form

This form is intended for use by contractors to notify CSUMB's Environmental Health, Safety and Risk Management department.

Please contact your supervisor/manager about reporting to work in-person (including access to mailroom, etc.) after you were tested for COVID-19 and while you wait for results.

Contactors include:

Greystar
UG2 Janitorial
Orkin Pest Control
IPM Pest Mgt.
Eagle Shield Pest Controls
Gothic Landscaping
Johnson Controls
TK Elevator
OTIS Elevator
Compass/Chartwell Dining
Follett Campus Store

First Name

Last Name

Phone Number

E-Mail

Mobile Opt In

Is the above number you provided able to receive text messages, may we text you about this COVID-19 Report?

What are you reporting?

I am reporting that I have tested positive for COVID-19.I am reporting a positive COVID-19 case on behalf of another individual.I am reporting being a close contact to someone that has tested positive for COVID-19.I am reporting being a close contact to someone I believe to be positive for COVID-19.I am feeling COVID like symptoms, but have not yet been tested.

How are you associated with CSUMB

ContractorOther

How are they associated with CSUMB

Contractor
Other

Choose which best describes your interactions with CSUMB.

RemoteOn-CampusOn-Campus and Remote

What best describes their interactions with CSUMB.

RemoteOn-CampusOn-Campus and Remote

Where are you currently living?

I currently live in CSUMB on-campus student housing.I currently live in Fredrick Park / CSUMB east campus housing.I currently live in Schoonover Park / CSUMB east campus housing.I currently live off-campus within Monterey County.I currently live off-campus in California outside of Monterey County.I currently live off-campus outside of California.

What building do you live in?

Please enter your room number.

Please enter your east campus street and apartment number.

Have you been on campus recently?

YesNo

Please enter all the locations you visited while you were on campus.

Building Name

Date

Entry Time

Exit Time

Close Contacts

A close contact is anyone who was within 6 feet of an infected person for a total of 15 minutes or more. A person is still considered a close contact even if they were wearing a mask while they were around someone with COVID-19.

Enter as much information as you can

First Name

Last Name

E-mail Address

Phone Number

Please select what best describes your relationship to the close contact.

StudentRoommate

Co-Worker

Other

Is there anyone else you may have been in contact with but do not know their name or email address?

YesNo

Enter as much information as you can about others you may have been in close contact with.

Fever ≥ 100.4°F	Subject fever
Chills	Short of breath
Cough	Sore throat
Fatigue	Body aches
Nausea, vomit, diarrhea	Headache
New loss of taste	New loss of smell